Protective role of arachidonic acid against diabetic myocardial ischemic injury: a translational study of pigs, rats, and humans

Aim Patients with diabetes mellitus have poor prognosis after myocardial ischemic injury. However, the mechanism is unclear and there are no related therapies. We aimed to identify regulators of diabetic myocardial ischemic injury. Methods and results Mass spectrometry-based, non-targeted metabolomic approach was used to profile coronary sinus blood from diabetic and non-diabetic Bama-mini pigs at 0.5-h post coronary artery ligation. Six metabolites had a |log2 (Fold Change)|> 1.3. Among them, the most changed is arachidonic acid (AA), levels of which were 32 times lower in diabetic pigs than in non-diabetic pigs. The AA-derived products, PGI2 and 6-keto-PGF1α, were also significantly reduced. AA treatment of cultured cardiomyocytes protected against cell death by 30% at 48 h of high glucose and oxygen deprivation, which coincided with increased mitophagic activity (as indicated by increased LC3II/LC3I, decreased p62 and increased parkin & PINK1), improved mitochondrial renewal (upregulation of Drp1 and FIS1), reduced ROS generation and increased ATP production. These cardioprotective effects were abolished by PINK1(a crucial mitophagy protein) knockdown or the autophagy inhibitor 3-Methyladenine. The protective effect of AA was also inhibited by indomethacin and Cay10441, a prostacyclin receptor antagonist. Furthermore, diabetic Sprague Dawley rats were subjected to coronary ligation for 40 min and AA treatment (10 mg/day per animal gavaged) decreased myocardial infarct size, cell apoptosis index, inflammatory cytokines and improved heart function. Scanning electron microscopy showed more intact mitochondria in the border zone of infarcted myocardium in AA treated rats. Lastly, diabetic patients after myocardial infarction had lower plasma levels of AA and 6-keto-PGF1α and reduced cardiac ejection fraction, compared with non-diabetic patients after myocardial infarction. Plasma AA level was inversely correlated with fasting blood glucose. Conclusions AA protects against diabetic ischemic myocardial damage by promoting mitochondrial autophagy and renewal, which is related to AA derived PGI2 signaling. AA may represent a new strategy to treat diabetic myocardial ischemic injury. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-024-02123-3.


Introduction
The risk of myocardial infarction in patients with diabetes mellitus (DM) is 2-4 times higher than those without DM, especially in the elderly [1,2].DM increases infarct size and impairs heart functional capacity.Moreover, diabetic patients have higher incidence of re-infarction, heart failure and death, compared with non-diabetic patients [3][4][5][6][7].
Currently, the most commonly used treatment for diabetic patients with myocardial infarction (MI) is percutaneous coronary intervention (PCI) [8].However, the incidence of slow flow and no reflow after primary PCI, often related to microangiopathy and microvascular dysfunction, is markedly higher in diabetic patients [9,10].Current available cardioprotective drugs are not satisfactory for myocardial ischemic patients with DM [11,12].As a result, diabetic patients with myocardial infarction show a poor clinical prognosis and outcome compared with non-diabetics.Effective mitigation of ischemic injury in diabetic patients remains an unmet medical need.
In this study, we aimed to apply a non-targeted metabolomics technique to investigate metabolic fingerprints of coronary sinus blood at the early stage after coronary artery ligation in mini-pigs with or without DM and explore new targets for the treatment of diabetic myocardial ischemic injury.

Materials and methods
Detailed materials and methods are in the online-only Additional file 1.The data associated with this study are available from the corresponding author upon reasonable request.

Induction of DM and myocaridal ischemia in mini-pigs and rats
Thirty-four Bama-mini pigs, half male and half female, weighed 25.5 ± 3.6 kg, were purchased from Northeast Animal Research Institute, China (license number: 230502600072021).Thirty Sprague Dawley rats, half male and half female, 352 ± 36 g, were purchased from Beijing Vital River Laboratory Animal Technology Co. Ltd. (license number: Beijing ICP No. 15004894-1).All animal experiments conform to the guidelines from Directive 2010/63/EU of the European Parliament on the protection of animals used for scientific purposes.DM animal model was established by administration of streptozotocin (STZ), as previously described [13,14].Briefly, STZ was administered intravenously to mini-pigs at 150 mg/kg and intraperitoneally to rats at 25 mg/kg, for consecutive 7 days.Fasting blood glucose (FBG) concentration higher than 7 mM was considered as successful disease induction.
Pig myocardial infarction model was established by coronary artery ligation.After ~ 16 h fasting, general anesthesia was intramuscularly administered in Bamapigs with ketamine (35 mg/kg) and diazepam (1.5 mg/ kg).A 14-French cuffed endotracheal tube was used for intubation in pigs and ventilation was administered at 15 mL/kg and FiO 2 at 100%.During this time, pigs were maintained with half doses of ketamine (15 mg/kg, i.v. per 1−2 h) and diazepam (0.75 mg/kg, i.v. per 1−2 h).The animal was fixed on the operating table in the right lateral position, and the heart rhythm was monitored by M8005A (Philips Medizin Systeme Boeblingen GmbH, Germany).An artery sheath catheter was inserted into the femoral artery of the right hind limb for coronary angiography.Under aseptic conditions, the chest was opened in the fourth intercostal space on the left side of the animal and the left anterior descending coronary artery (LAD) was ligated between the first diagonal branch (D1) and the second diagonal branch (D2) for 90 min in MI group and DM + MI group.Electrocardiogram showed typical myocardial ischemic changes, such as the ST-segment elevation, T-wave inversion.Animals in sham group were only threaded and not ligated.
As for rat myocardial infarction model, rats were anaesthetized by intraperitoneal injection of sodium pentobarbital (40 mg/kg body weight), and LAD was ligated for 40 min using a 6-0 Prolene suture under a dissecting microscope (Leica), and then the ligature was released.Myocardial ischemia was confirmed by the anterior wall of the LV turning pale and ST-segment elevation on the electrocardiogram (ECG).The experimental protocol was approved by Institutional Animal Care and Use Committee of Fuwai Hospital.
At study endpoints, all pigs were anaesthetized with an intraperitoneal injection of ketamine (35 mg/kg) and diazepam (1.5 mg/kg) and then intravenous injection of 10% KCl, 15-20 mL under deep anesthesia.All rats were euthanized by an intraperitoneal injection of sodium pentobarbital (120 mg/kg body weight).

Non-targeted metabolomic measurement
To determine the metabolic features in diabetic pigs with MI, ten milliliter of Bama mini-pig coronary sinus blood was collected at 0.5 h after LAD ligation and centrifuged at 13,000 rpm for 20 min to obtain plasma.Then, the plasma sample was mixed with methanol in a ratio of 1:4 for 2 min, vortexed and centrifuged at 13,000 rpm, and 4 °C for 15 min.The supernatant (1200 μL) was collected, transferred to a new 1.5 mL polypropylene tube, and dried in a vacuum drying oven.Each sample was dissolved by adding 150 μL of 50% methanol, followed by filtration with a 0.22-μm Millipore filter before injection.
A Waters Q/TOF Premier mass spectrometer (Waters, Corp., Manchester, UK) connected to an electrospray ionization source (ESI) was used for mass spectrometry analysis.The mass spectrometry detection parameters were as follows: capillary voltage, 3.0 kV; extraction cone voltage, 4.0 V; sample cone voltage, 30 V; collision energy, 5 eV; desolventizing gas flow rate, 600 L/h; desolventizing temperature, 300 °C; cone gas volume, 50 L/h; source temperature, 100 °C; scan range m/z 50-1000 Da, scan time and delay time between scans were both set to 0.02 s.In order to ensure accuracy and repeatability at a concentration of 200 ng/mL and a flow rate of 20 μL/min, the LockSpray interface was used to obtain all data.
The MarkerLynx Application Manager (Waters, United States) was used to recognize original chromatographic peak data obtained from the UPLC/ESI-Q-TOF/MS system.The main parameters were as follows: retention time (RT), 0−24 min; mass, 50−1000 Da; mass tolerance, 0.2 Da; minimum intensity, 1%; mass window, 0.05, RT tolerance, 0.02 min; and noise elimination level 6.Pattern recognition analysis is a common and practical method in metabolomics research.In this article, PLS-DA model was built by Simca-P software (version 11.5, Demo, Umetrics, Umea, Sweden) and used to concentrate the group discrimination into the first component, while the remaining unrelated variation was contained in the subsequent components.Based on the significance values and screening of the score and loading plots, the differential metabolites were found.Use #5 ppm as the detection window and rely on the METLIN metabolite database to identify the resulting metabolites.According to the mass accuracy (m/z), each metabolite was presumably identified.

Patients
Thirty subjects were included in this study: 10 heathy volunteers, 10 diabetic and 10 non-diabetic patients who were admitted to the emergency department within 4 h of the onset of myocardial infarction symptom according to the statement of the patients or their family.The daily dose of aspirin taken by the selected patients in this study was less than or equal to 150 mg, and no aspirin or anti-diabetic drugs had been used at least 8 h before the visit.After obtainment of written informed consent, plasma was collected from subjects and stored in aliquots at − 80 ℃ for AA and its metabolites determination.The study protocol was approved by the Ethics Committee of Nanjing Drum Tower Hospital, and conformed to the Declaration of Helsinki.

Statistical analysis
All statistical analyses in this study was performed using GraphPad Prism (version 6.01) software (GraphPad Software, Inc, San Diego, CA).When only 2 groups were involved, student 2-tailed unpaired t test was used for comparison.Comparisons of multiple groups were made using a 1-way ANOVA analysis.Tukey or Biferonnii post hoc tests were performed for the data with equal variances, whereas Dunnett post hoc tests were used for data with unequal variances.And Bartlett tests were used for analyzing the variances of data.Results are expressed as mean ± standard deviation.Differences were considered statistically significant at P < 0.05.
The differentially regulated metabolites were analyzed for pathway enrichment using MetaCore (Genego, St. Joseph, MI).Metabolite identifiers (CAS and KEGG) were used for each metabolite including name and molecular weight and fold change.The ratio of significantly changed metabolites in the pathway to total number of metabolites in a pathway was also calculated.Their significance was determined by hypergeometric test's p-values.A P value < 0.05 is indicative of significant enrichment.Biferonnii correction was applied to correct for multiple testing.A false discovery rate of < 0.15 was required.

Induction of diabetes and acute myocardial ischemia in mini-pigs
First, we established a Bama-mini pig model of diabetes by intravenous injection of STZ (Fig. 1A).The fasting blood glucose (FBG) of diabetic animals was higher than 7 mM for 7 consecutive days, which met the diagnostic criteria for diabetes (Fig. 1B).Coronary angiography showed the ligation site was at the lower 1/2-1/3 of left anterior descending branch (Fig. 1C).ECG showed ST-segment elevation and high-point T wave (Fig. 1D).The affected myocardium in the MI group was mainly the anterior wall and anterior septum of the left ventricle, while in the DM + MI group, the affected myocardia included not only anterior wall, anterior septum, but also part of side wall of left ventricle (Fig. 1E).The left ventricular ejection fraction (LVEF) in MI group trended lower (but without statistical significance), compared with sham group.However, the LVEF of DM + MI group, was substantially lower (49.9 ± 3.5% vs. 62.8% ± 4.9%, P < 0.05) than that of MI group (Fig. 1F).Two hours post surgery, in comparation with sham group, cardiac troponin I (cTn I) concentration increased significantly in MI group (3.25 ± 0.53 ng/mL vs. 0.063 ± 0.02 ng/mL, MI vs. sham, n = 10 in each group, P < 0.05) and in DM + MI group (5.39 ± 0.96 ng/mL vs. 0.063 ± 0.02 ng/mL, DM + MI vs. Sham, n = 10 in each group, P < 0.01) (Fig. 1G).To further examine myocardial infarction location, size, and transmural extent between the diabetic and non-diabetic pigs, MRI was performed 48 h after surgery.Infarcted myocardium was in anterior wall of left ventricle in MI group, while infarction of DM + MI group was not only in the anterior wall, but also in the side wall and ventricular septum, which was also more transmural (Fig. 1H).Consistently, 2,3,5-triphenyltetrazolium chloride (TTC) staining at 48 h post MI (Fig. 1I) showed that compared with sham group, the MI and DM + MI groups had obvious myocardial infarction lesions, and myocardial infarct size in DM-MI group was much larger than that in MI group (33.2 ± 5.6% vs.15.6 ± 2.3%, P < 0.05, Fig. 1J).The scanning electron microscope results showed that compared with non-diabetic pigs, diabetic miniature pigs had more severe damage to mitochondria in the myocardial cells around the infarcted myocardium, and the percentage of normal mitochondria decreased significantly (Fig. 1K, L, P < 0.05).Mitophagosomes were found in both groups of myocardial cells (Fig. 1M).

Non-targeted metabolomic profiling of coronary sinus blood of pigs with MI and DM
To identify mediators of diabetic myocardial ischemic injury, non-targeted UPLC-qTOF-MS metabolomic approach was used to analyze the venous sinus blood collected at 0.5 h after the coronary ligation operation (Fig. 2A) and the variable importance in the projection value of the first principal component of the OPLS-DA (Fig. 2B) was used to find differentially regulated metabolites (Table 1).Identification of the metabolites was based on accurate mass measurements and chromatographic retention time (RT).As shown in Table 1, there were 11 metabolites that were differentially regulated between the diabetic and non-diabetic groups.Two major parameters were considered: adjusted P < 0.05 combined with |log 2 (Fold Change)|> 1 Compared with the sham group, the increased metabolites in the MI group and the MI + DM group included glucose and cholesterol, and the decreased metabolites included arachidonic acid (AA), glutamine, prostaglandin (PG) I 2 (PGI 2 ), 6-keto-PGF 1α , and L-proline.However, when comparing the blood metabolites of coronary sinus of DM + MI with MI, four decreased metabolites had a |log 2 (Fold Change)|> 1.3, the concentration of AA decreased nearly 32 times (P < 0.05), the concentration of PGI 2 and 6-keto-PGF 1α decreased by about 7 times and 11 times, respectively.Pathway enrichment analysis identified enriched metabolic pathways of the differentially regulated metabolites.The calculation P-value takes FDR (false discovery rate) < = 0.05 as a threshold.Pathways meeting this condition were defined as significantly enriched pathways.AA metabolism pathway for which FDR is 0.009, hits 3 metabolites, and has the highest impact (0.45) (Fig. 2C, D, Table 2).Hence, we next focused on the function and mechanism of AA.Furthermore, we collected myocardial tissue in the border zone of the infarct lesions and measured the activity of phospholipase A2 (PLA2), a rate limiting enzyme that catalyzes the release of AA from plasma membrane phospholipids.The activity of PLA 2 in the myocardium around the infarction area of diabetic pigs was significantly reduced when compared with non-diabetic pigs (0.47 ± 0.16 vs.2.06 ± 0.57, P < 0.001) (Fig. 2E), which might explain the plasma AA reduction in the diabetic myocardial ischemia (Fig. 2F).

AA supplementation protected cardiomyocytes from apoptosis in vitro under hyperglycemic and hypoxia condition
To clarify the role of AA in diabetic myocardial ischemic injury, we first applied high glucose (HG) and oxygen deprivation (OGD) to rat embryo cardiomyocytes (H9C2) to simulate diabetic myocardial ischemia, and then measured intracellular AA production.HG + OGD treatment lowered intracellular AA levels (Fig. 3A) in a time-dependent manner (Fig. 3B).At the same time, exposure to HG + OGD induced greater loss in H9C2 cell viability compared with that of the HG or OGD groups (Fig. 3C).TUNEL staining, which detects DNA breaks in apoptotic cells and necrotic cells, showed that the TUNEL positive cells in the HG + OGD group was markedly higher than those in the HG or OGD group.These in vitro results indicated that combination of HG and OGD decreased intracellular AA level and increased cardiomyocyte apoptosis (Fig. 3D, E).We next examined the effect of exogenous AA on cell viability.Addition of AA (1-25 µM) decreased TUNEL-positive nuclei and increased cell viability (Fig. 3F) in a dose-dependent manner, which indicated a cardiomyocyte-protective effect of AA.The least number of apoptotic cells was found in the group treated with 25 µM AA.Therefore, AA at this concentration was used in subsequent experiments to elucidate the potential protective mechanism of AA.

AA supplementation decreased intracellular and mitochondrial ROS (mt ROS) production and improved mitochondrial function
To delineate potential mechanisms of AA in protecting cardiomyocytes, we measured intracellular generation of ROS, a known mediator of diabetic and ischemic injury.DCFH-DA fluorescent staining assay showed that the levels of intracellular ROS were higher in HG + OGD group relative to HG or OGD group.AA supplementation suppressed intracellular free radicals up-regulation in H9C2 cells grown in HG and OGD group (Fig. 4A,  B).We next examined mitocondrial ROS (mtROS) production in the presence or absence of AA (25 µM).In HG + OGD group, mtROS production increased significantly in comparation with the control group.However, this increase was reversed by supplementation of 25 µM AA. (Fig. 4C, D).
ATP production is an important indicator of the functional status of mitochondria [16].After HG + OGD treatment, the ATP production of cardiomyocytes was significantly lower than that of the control group, which was relieved by 25 µM AA treatment (Fig. 4G; P < 0.05), indicating that AA salvaged the mitochondrial function of myocardial cells.

AA activated PINK1-Parkin-dependent mitophagy, inhibited mitochondrial loss and improved mitochondrial turnover
HG + OGD decreased expression of LC3II/I (Fig. 5A) and increased that of p62 (Fig. 5B), which was reversed by treatment with AA.It also showed that (See figure on next page.)Fig. 2 Metabolites (up-and down-regulated) and related pathways modulated by DM in pigs with MI identified by metabolomic profiling of coronary sinus blood.Half hour after myocardial infarction, blood was collected from the coronary sinus for metabonomic analysis.A Representative base peak intensity (BPI) chromatograms from Bama-minipig plasma samples.The box indicates the BPI with a retention time of about 24 min, at which time AA is identified.B Two dimensional scores plot of a PLS-DA with orthogonal signal correction data filter of the first and second PLS component of plasma.The solid square represented sham group, blank squares represented MI group, and the solid triangles represented DM + MI group.C The map of differentially regulated metabolites; D pathway enrichment analysis identified AA metabolic pathway enriched most significantly.The calculated P-value was gone through FDR Correction, taking FDR ≤ 0.05 as a threshold.n = 10 in each group.E Determination of the concentration of PLA2; F schematic diagram of PLA2-catalyzed dissociation of AA from cell membranes in the context of acute myocardial ischemia in diabetes.P-values were obtained using an unpaired t-test.***P < 0.001.Statistical analysis was carried out by a one-way ANOVA analysis.AA, arachidonic acid; MI: acute myocardial infarction; BPI: base peak intensity; DM: diabetes mellitus; PLS-DA: partial least squares discriminant analysis.PLA2: phospholipase A2 AA supplementation inhibited HG + OGD induced decrease in PINK1 and Parkin (Fig. 5C, D) which are the key proteins in mitophagy pathway [17].Further, AA supplement improved mitochondrial turnover under HG + OGD condition by up-regulating the expression level of mitochondrial dynamin-related protein 1 (Drp1) and mitochondrial fission protein 1 (FIS1) (Fig. 5E, F).The real-time PCR results showed that compared with the control group, the ratio of mitochondrial to genomic DNA (mtDNA:gDNA) in the HG + OGD group was significantly reduced (P < 0.05), which was also reversed by AA treatment (Fig. 5G).
Mitochondrial damage or dysfunction leads to the release of cytochrome c into the cytoplasm.The cleavage or activation of caspase 3 is an important sign of apoptosis [18].We measured the levels of cytochrome c in mitochondria and cytoplasmic components, as well as the concentration of cleaved caspase -3 protein in control and HG + OGD groups with or without AA treatment.Western blot analysis revealed that 25 µM AA prevented the release of cytochrome c from mitochondria to cytoplasm (Fig. 5H, I).Moreover, compared with the HG + OGD group (0 µM AA), there was no significant difference in the levels of caspase 3 cleaved at 17-kDa and 19-kDa in 1 µM or 5 µM AA group, but 25 µM AA significantly reduced the level of cleaved caspase 3 (Fig. 5J).

PINK1 specific siRNA and 3-MA abolished the beneficial effect of AA on cardiac myocytes
To study whether the cytoprotective effect of AA under the condition of HG + OGD is dependent of Parkin-PINK1 mediated mitophagy, we treated myocardial cells with PINK1-specific siRNA and autophagy inhibitor 3-Methyladenine (3-MA).AA (25 µM) significantly up-regulated the levels of LC3II/LC3I (the conversion of LC3I to LC3II) and down-regulated the level of p62, compared with that in control group and this was reversed by siRNA or 3-MA (Fig. 6A, B).In PINK1-siRNA group, siRNA effectively silenced PINK1 gene expression (Fig. 6C).Parkin protein showed no difference between PINK1-siRNA group and 3-MA group, but it was decreased significantly compared with that in AA group.(Fig. 6D).
Meanwhile, both 3-MA and PINK1-siRNA reversed AA-induced up-regulation of Drp1 and FIS1.The inhibitory effect of PINK1-siRNA was more significant than 3-MA (P < 0.05).(Fig. 6E-F).In the 3-MA and PINK1-siRNA pretreatment group, AA failed to prevent mitochondria from releasing cytochrome C into cytoplasm, and formation of cleaved caspase 3 induced by HG + OGD (Fig. 6G-I).The mitochondrial gene levels also failed to be improved, indicating that the cardiomyocyte protective effect of AA is dependent on mitophagy (Fig. 6J).

Inhibition of cyclooxygenase and prostacyclin signaling blunted the protective effect of AA on cardiomyocytes
Cyclooxygenase (COX) is a rate-limiting metabolic enzyme of AA, and PGI 2 is a well-known cardioprotective metabolite of this pathway [19].As the metabolomics analysis showed, the levels of PGI 2 and 6-keto-PGF 1α in the coronary sinus blood of diabetic mini-pigs were significantly decreased following myocardial ischemia.In order to prove whether this pathway is related to the myocardial protection of AA, we used the COX inhibitor indomethacin and PGI 2 receptor inhibitor Cay10441 to block this pathway.After Cay10441 (Fig. 6K) treatment, the protective effects of AA on cardiomyocyte mitophagy and mitochondrial self-renewal processes were suppressed, and indomethacin also showed similar effects (Fig. 6L).

AA protected against diabetic myocardial ischemic injury in rats with DM and MI
Compared with non-diabetic rats, the infarct size increased significantly in DM + MI group (37.7 ± 4.6% vs.53.2 ± 3.2%, MI vs.DM + MI, P < 0.001), which decreased by ~ 38.2% after AA treatment.(Fig. 7A, B) TUNEL staining of ischemia risk area around infarction showed that AA decreased apoptosis index (AI) significantly in diabetic rats, compared with DM + MI model control group (66.8 ± 1.8% vs. 29.3± 2.2%, DM + MI vs. DM + MI + AA, P < 0.05) (Fig. 7C, D).HE staining showed that AA treatment increased the number of blue nuclei under DM + MI condition.Electron microscopy showed that myocardial fiber breakage, light-dark band fusion, mitochondrial swelling and sputum disappearance was significantly improved by AA treatment.
It is known that DM is characteristic of recurrent hyperglycemia due to insufficient insulin production or insulin dysfunction, and hyperglycemia leads to an exaggerated inflammatory response [20] and the production of a large amount of ROS, which can inactivate many enzymes, including metabolic enzymes of AA [21,22].
In our study, serum concentrations of inflammatory cytokines IL-1β, IL-6 and TNF-α in diabetic/nondiabetic SD rats with or without AA treatment were detected, results revealed that.IL-1β, IL-6 and TNF-α were all significantly increased in the diabetic group compared with the non-diabetic group (DM + MI vs.MI, P < 0.001). .AA treatment reversed the increase of inflammatory factors IL-1β, IL-6 and TNF-α in both diabetic (DM + MI vs. DM + MI + AA, P < 0.001) and non-diabetic rats (MI vs. MI + AA, P < 0.001) (Fig. 7 E-G).Malondialdehyde (MDA), a indicator of overall oxidative stress level, was significantly increased in myocardiacytes in the peri-infarct region of rats in DM + MI group, and AA treatment normalized the MDA levels.Total antioxidant capacity (T-AOC) of myocardial tissue in the periphery of infarction in the DM + MI + AA group was significantly higher than that of the DM + MI group, and similar to that of the control group, suggesting that AA treatment enhanced the rat's ability to resist oxidative stress (Table 3).Next, the activity of PLA 2 in the border zone of infarcted myocardium in diabetic rats with or without AA treatment was determined.Similar to the pig study and the PLA 2 activity of rats in the DM + MI group was significantly lower than that in the MI group, AA treatment significantly alleviated the damage to PLA 2 activity caused by diabetic myocardial ischemia (Fig. 7H).
Furthermore, the expression of mitophagy and mitochondrial regenerative proteins in the border zone of infarcted myocardium were determined by western blot.As shown in Fig. 7I-N, AA treatment restored the mitophagic flux (as indicated by increased LC3II/LC3I decreased p62, and increased PINK1 and parkin), enhanced the mitochondrial renewal (increased Drp1 and FIS1), suggesting a role of PINK1-parkin dependent mitophagy pathway in mediating the cardioprotective effect of AA.

Reduced AA concentrations in diabetic patients with MI and its correlation with FBG as well as cTnI
To further examine the relevance of AA to diabetic myocardial ischemia injury, blood concentrations of cTnI, AA and 6-keto-PGF 1α of the enrolled patients were detected.Compared with the control group, the serum cTnI levels in both MI group and DM + MI group were significantly increased, and the serum cTnI levels in DM + MI group were higher than those in MI group (4.6 ± 0.3 ng/mL vs. 2.7 ± 0.1ng/mL, DM + MI vs. MI, P < 0.001) (Fig. 8A).Compared with non-diabetic patients, diabetic patients with MI had lower blood levels of AA (4.6 ± 0.8 vs.7.3 ± 1.4 mM, DM + MI vs. MI, P < 0.05, Fig. 8B) and Fig. 6 The cardiac myocytes protective effect of AA was inhibited by mitophagy and AA-COX-PGI pathway inhibitors.H9C2 cells were pretreated with PINK1 specific siRNA (120 nM), 3-MA (10 mM), Cay10441 (10 μM) or Indomethacin (5 μM) before AA supplement (25 µM) under the condition of HG + OGD.Mitophagy associated proteins LC3II/LC3I (A), p62 (B), PINK1 (C) and Parkin (D); mitochondrial renewal proteins Drp1 (E) and FIS1 (F); cytosolic cytochrome c (cyt c) and mitochondrial cyt c (G, H), as well as cleaved caspase-3 (I) in each group were measured by western blot.GAPDH and VDAC1 were used as internal protein loading controls respectively for cytosolic and mitochondrial protein.Optical densities of the protein bands were quantitatively analyzed with Sigma Scan Pro 5 and normalized with loading control GAPDH or VDAC1.J the ratio of mitochondrial DNA and genomic DNA (mtDNA/gDNA).To detect whether the effect of AA on mitochondria was associated with AA-COX-PGI2 pathway, PGI receptor inhibitor Cay 10,441(K) and COX inhibitor Indomethacin (L) was used.Results are expressed as the mean ± SD. *P < 0.05, **P < 0.01 and ***P < 0.001.Statistical analysis was carried out by a one-way ANOVA analysis 6-keto-PGF 1α (13.9 ± 3 vs.51.6 ± 2.9 ng/mL, DM + MI vs. MI, P < 0.05, Fig. 8C).Echocardiography indicated that the cardiac functional capacity of diabetic MI patients was significantly reduced compared with that of non-diabetic MI patients (EF, 54 ± 3% vs.38 ± 5%, MI group vs. DM + MI group, P < 0.05) (Fig. 8D, E).Then, the relation of plasma AA with fasting blood glucose (FBG) and cTnI was analyzed.Results showed a correlation of AA with FBG (coefficient: 0.771, R 2 > 0.7) (Fig. 8F) and a correlation of AA with cTnI (coefficient: 0.217, R 2 < 0.3) (Fig. 8G).Thus, these human data support again that AA metabolism is key to diabetic myocardial ischemic injury.
Taken together, the data obtained from, pigs, rats and patients, and cell experiments support a key protective role of AA in diabetic myocardial ischemia, and the underlying mechanism is schematically illustrated (Fig. 8H).

Discussion
In patients with DM, energy metabolism remodeling, particularly glycolipid metabolism disorder is a major mechanism underlying myocardial ischemic injury [23].In this study, we found that AA, an omega-6 polyunsaturated fatty acid, robustly protected cardiomyocytes in the early stage of diabetic myocardial ischemic injury.
AA exists in the cell membrane in the form of phospholipid and is the most abundant and widely distributed polyunsaturated essential fatty acid in human.It plays an important role in maintaining the structure and function of cell membrane.As an important precursor of prostaglandin synthesis.AA has extensive biological activity and important nutritional effects [24].After stimulation, it is released from the plasma membrane by Fig. 7 AA treatment reduced MI injury in diabetic rats.SD rat subjected to STZ (25 mg/kg, intraperitoneally) and LAD ligation-reperfusion surgery.AA treatment: freshly prepared AA in phosphate buffered saline (PBS) was administered orally once per day at a dose of 10 mg/animal for 1 week before operation and 72 h post operation.The rat in the control group were given vehicle (PBS solvent).A Representative images of TTC staining.The non-TTC staining area indicates the infarcted lesion; B quantification of myocardial infarct size with or without AA treatment.C Representative images of the ischemic myocardium analyzed by TUNEL assay and H&E staining.Scale bars in TUNEL and H&E staining are 20 μm.D Apoptosis index (AI) in TUNEL assay.AI is identified by dividing the number of TUNEL-positive cells (green) by the total number of cells (blue DAPI) visualized in the same field.Three independent experiments were averaged and statistically analyzed.E-G determination of proflammatory cytokines in diabetic/non-diabetic rats with or without AA treatment.H determination of PLA2 activity, I−N western blot was used to determine the expression level of mitophagy-and mitochondrial turnover-related proteins.quantification of optical densities of the protein bands with Sigma Scan Pro 5 and normalized with loading control GAPDH.Results are expressed as the mean ± SD. n = 6.*P < 0.05, **P < 0.01 and ***P < 0.001.ns means no statistically significant difference.Statistical analysis was carried out by a one-way ANOVA analysis activated PLA2 [25,26].Treatment with ARASCO oil, a rich source of AA, significantly suppressed inflammation, and reversed altered antioxidant status to near normal in animals with high fat fed and STZ induced diabetes [27].
In a previous study, AA was increased in patients with acute MI within the previous 1-6 months compared with control group [26].Another study showed that AA was reduced in diabetic rats [28], and it may play critical role in regulation of cytochrome P450 metabolites in diabetic rats with cardiac injury [29].However, these studies did not describe the time-course changes of AA concentration and its biological function in diabetic myocardial infarction.
Here, our metabolomics data on the early stage of MI in diabetic pigs showed AA decreased ~ 32-fold compared with non-diabetic pigs.AA metabolism was decreased in the early stage of MI, especially in the diabetes group compared to the control group.In cell experiments, 25 µM of AA protected cardiomyocytes from apoptosis.AA treatment salvaged the cardiac functional capacity of diabetic SD rats and reduces the area of myocardial infarction.
AA is the precursor to a number of pro/anti-inflammatory and pro/anti-aggregatory mediators (such as prostaglandins, thromboxanes, leukotrienes, and other oxidized derivatives) and regulates cell viability and function [30][31][32][33].Sub-micromolar concentrations of AA exhibit diverse physiological activities such as esterifying free fatty acid, reducing blood levels of free fatty acids, regulating vascular elasticity, blood viscosity and blood cell function [34,35].In the setting of diabetic myocardial infarction, ischemic injury damages mitochondria, and the dysfunctional mitochondria produce reactive oxygen species (ROS) [36], which aggravates oxidative stress damage, which may provide a reasonable explanation for the decreased PLA2 activity found in diabetic animals in this study.Previous studies reported that AA alleviated ROS damage by inhibiting the activity of NADPH oxidase [37] and nitric oxide synthase [38].Here, we demonstrated that AA supplement decreased mitochondria-derived ROS, inhibited the dissipation of mitochondrial transmembrane potential (ΔΨm), decreased mitochondrial oxidative damage and restored mitochondrial function, and, importantly, these effects were dependent on AA derived PGI 2 .
Damaged mitochondria are recognized by autophagosome and fused with lysosomes, a biological process termed as 'mitophagy' [39].In this process, damaged mitochondria initiate a series of biological events, including the stabilization of PINK1 on depolarized mitochondria, phosphorylation of Mfn2, and recruitment of parkin to damaged mitochondria [40,41], and the cargo complex is ubiquitinated and then delivered to the autophagosome through the receptor protein p62/ SQSTM1 [42].When autophagy flux is enhanced, the number of autophagosomes increases, conversion of LC3I to LC3II increases, and the expression level of LC3II protein increases, but the content of autophagy substrate receptor p62/SQSTM1 in the cell decreases [42].In this study, we found that in cardiac myocytes with HG + OGD Mitophagy is also important to mitochondrial selfrenewal.The regulation of mitochondrial dynamics is mainly controlled by specific proteins, among which Drp1 and FIS1 are core molecules [43,44].Here, AA treatment enhanced the expression levels of Drp1 and FIS1, mtDNA:gDNA and ATP production in cardiac myocytes (Fig. 6).Furthermore, AA decreased inflammatory cytokines (Fig. 7), MDA and increased T-AOC in rat myocardium (Table 3).These data indicate that AA promotes mitochondrial turnover.
Mitochondrial dysfunction may lead to release of cytochrome c from mitochondria to cytosol and induces cell apoptosis, which is one of the classical pathways of mitochondrial apoptosis (endogenous apoptosis).Caspase-3 is the executor of apoptosis, and the activation and high-level expression of casepase-3 is also an important indicator of apoptosis.In this study, high glucose and hypoxia caused mitochondrial damage, while AA protected mitochondria and reduced cell apoptosis.As shown in Figs. 5, 6, high glucose and ischemic injury resulted in increased cytochrome C expression in the cytosol and decreased cytochrome C expression in the mitochondria, suggesting an endogenous apoptotic pathway.AA treatment inhibited the release of cytochrome C, reduced the expression of 17-, 19-KDa-activated caspase 3 protein, thereby inhibited the activation of caspase 3 and the endogenous withering pathway.Thus, AA reduced high glucose and ischemic injury-induced apoptosis by inhibiting the endogenous apoptotic pathway.
Treatment with inhibitors of prostaglandin synthesis or PGI 2 receptor attenuated AA's promotion of mitophagy and mitochondrial turnover in high-glucose hypoxic cardiomyocytes, suggesting the protective effect of AA on diabetic myocardial ischemia is related to the AA-PGI 2 metabolic pathway.PGI 2 produced during cardiac I/R protects cardiomyocytes independent of its effects on platelets and neutrophils [45].PGI 2 may bind to the PGI 2 receptors and PGE 2 receptors, and then initiate the opening of mitochondrial ATP-sensitive potassium (K-ATP) channels, thereby reducing myocardial ischemia-reperfusion injury and limiting oxidation damage [46].K-ATP inhibits dopaminergic neurodegeneration by activating mitophagy in Parkinson's disease [47].Previous studies have demonstrated that the activation of PGI 2 receptors significantly attenuated hypoxia-induced pulmonary artery remodeling through dissociation of raptor from mTORC1 [47].MTORC1 is a key factor in negatively regulating autophagy pathway.In this study, we demonstrated that the AA-PGI 2 metabolic pathway was inhibited in the early stage of myocardial ischemia in diabetes [48].AA supplementation significantly enhanced the activity of the AA-PGI 2 pathway, mitophagy, and promoted mitochondrial renewal.However, COX inhibitor (indomethacin), PGI 2 receptor inhibitor (Cay10441), mTORC1 mediated autophagic signaling pathway inhibitor (3-MA) or silencing of key genes in mitophagy pathway (PINK1-siRNA) reversed this biological effect of AA, which indicated that AA protected against diabetic ischemic myocardial damage by promoting mitochondrial autophagy and renewal, which is related to AA derived PGI 2 signaling (Fig. 8).
In summary, we report that ischemic injury under diabetic condition decreases cardiac release of AA, and AA supplementation protects cardiomyocytes from hyperglycema-and ischemia-induced injury in vitro and in vivo.This is attributable to PINK-parkin mediated mitochondrial autophagy, enhanced mitochondrial turnover and decreased cell apoptosis, which is PGI 2 dependent.AA might be beneficial for diabetic patients with or at risk of ischemic injury.
This study provides evidence from pigs, rats and patients showing that AA plays a pivotal role in protecting against diabetic myocardial ischemia injury.Nevertheless, clinical trial study is warranted to test its clinical translation.

Fig. 1
Fig.1 DM increased infarct size and impaired heart function in pigs with MI.Bama-mini pigs were first subjected to intravenous injection of STZ (150 mg/kg) to induce DM disease, and then underwent coronary artery ligation surgery to establish an acute myocardial infarction model.Hematology, coronary angiography, electrocardiogram, echocardiography, MRI, and TTC staining were used to evaluate the animals.SEM was used to detect the ultrastructural changes in cardiomyocytes in the peripheral area of infarction.A Study design.B FBGs of diabetic pigs post STZ administration; C Representative coronary angiography images of sham group (left), MI group (middle) and DM + MI group (right).The arrows show the coronary ligation site.D Representative images of electrocardiogram immediately after surgery.The arrows show the elevated S-T segment.E, Representative echocardiographs and F ejection fraction of mini-pigs was determined to evaluate cardiac function at 48 h after surgery.G Serum cTnI concentration was compared at 2 h after surgery.H Representative cardia MRI image from 10 animals.Red circle indicates the infarct area.I Representative images of TTC stained myocardium of mini-pigs.Red arrows indicated infarcted myocardia.J Quantification of infarct size.n = 10-12; K Representative images of SEM; L quantification of intact mitochondria.M analysis of the percentage of mitophagosomes.P-values were obtained using an unpaired t-test.*P < 0.05, ***P < 0.001.Statistical analysis was carried out by a one-way ANOVA analysis.DM, diabetes mellitus; MI, acute myocardial infarction; cTnI, cardiac troponin I; FBG, fasting blood glucose; LAD, left anterior descending coronary artery; MRI, magnetic resonance imaging; TTC,2,3,5-triphenyltetrazolium chloride; SEM, scanning electron microscopy

Fig. 3 Fig. 4 (
Fig. 3 Protection of AA against high glucose (HG) + oxygen deprivation (OGD) induced myocardial cell death.H9C2 cells were grouped into high glucose (HG, 33 mM), OGD, or HG + OGD.To establish the OGD cell model, cell culture medium was replaced with Tyrode's solution without glucose and the cell plate was moved into a controlled hypoxic chamber for 3 h.Then, intracellular AA concentration was detected with or without OGD + HG treatment, and MTT and TUNEL methods were used to determine the change of cell viability and apoptosis before and after AA treatment.A intracellular AA level; B the time-course changes in AA levels in HG + OGD treated H9C2.C The MTT assay was used to determine the cell viability.D TUNEL method was used to detect apoptosis induced by HG + OGD.E, F, effect of AA on HG + OGD treated H9C2 cells viability by MTT assay and cell apoptosis by the TUNEL assay.G Representative images of TUNEL assay, the blue spots represent cell nuclei (DAPI staining) and the green spots represent apoptotic bodies.The results are expressed as the mean ± standard deviation of data from 3 independent experiments; **P < 0.01, ***P < 0.001.Statistical analysis was carried out by a one-way ANOVA analysis.a.u.= arbitrary units

Fig. 5
Fig.5 The effect of AA on mitophagy, mitochondrial turnover and cell apoptosis.H9C2 cells were treated as described in Fig.2.Western blot was used to measure the expression of mitophagy associated proteins, mitochondrial renewal proteins and apoptosis-related factors.Real-time PCR was used to detect the level of mitochondria and genomic DNA.A-D quantification of mitophagy associated proteins LC3II/LC3I (A), p62 (B), PINK1 (C) and parkin (D); E, F quantification of mitochondrial renewal proteins Drp1 (E) and FIS1 (F); H-J, quantification of apoptosis-related factors cytosolic cytochrome c (cyt c) (H), mitochondrial cyt c (mito-cyt c) (I), and cleaved caspase-3 (J).GAPDH and VDAC1 were used as internal protein loading controls respectively for cytosolic and mitochondrial protein.Optical densities of the protein bands were quantitatively analyzed with Sigma Scan Pro 5 and normalized with loading control GAPDH or VDAC1.G mitochondrial to genomic DNA.Results are expressed as the mean ± SD. *P < 0.05, **P < 0.01 and ***P < 0.001.Statistical analysis was carried out by a one-way ANOVA analysis

Fig. 8
Fig. 8 Plasma AA concentration and cardiac function in patients with diabetic myocardial infarction and the molecular mechanism of AA cardioprotective effect.Serum cTnI and plasma AA & 6-keto-PGF 1α concentrations of diabetic and non-diabetic patients were detected 2−4 h after MI onset, and echocardiography was performed 4−5 h after MI onset.A The serum cTnI concentration of MI and DM + MI patients.B Plasma concentration of AA.C Plasma concentration of 6-keto-PGF 1α .D Representative images of echography.E Measurement of the ejection fraction.The ejection fraction of subjects with DM + MI decreased significantly.F Correlation analysis between FBG and AA.G Correlation analysis between blood cTnI and AA.H Schematic diagram of cardioprotection of AA in diabetic MI injury.**P < 0.01 and ***P < 0.001.Statistical analysis was carried out by a one-way ANOVA analysis.DM, diabetes mellitus; MI, acute myocardial infarction; HG: high glucose; OGD: oxygen deprivation; mtDNA:gDNA: mitochondrial DNA/genomic DNA; FBG: fasting blood glucose; cTnI, cardiac troponin I dUTP nick-end labeling UPLC/ESI-Q-TOF/MS Ultra-performance liquid chromatography/electrospray ionization quadruple time-of-flight mass spectrometry VDAC1 Voltage Dependent Anion Channel Protein 1

Table 1
Metabolites in coronary sinus blood differentially regulated between diabetic and non-diabetic pigs during MI Positive values in 'LOG 2 -fold change' column represent the relatively increased metabolites.Negative values represent the relatively decreased metabolites n = 10 in each group Rt: retention time; m/z: mass-to-charge ratio A: mean of DM + MI; B: mean of MI; C: mean of Sham group

Table 2
Metabolic pathway analysis (DM + MI vs. MI group)

Table 3
Concentrations of serum MDA and T-AOC in rats of different groups * P < 0.01, compared with MI † P < 0.05, compared with DM + MI group.Three independent experiments were averaged and statistically analyzed.n = 6 in each group *